Regulatory lessons from accidents due to institutional failures: Boeing 737 MAX and Deepwater Horizon

Nadezhda Gotcheva, Marja Ylönen

Research output: Book/ReportReport

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Regulatory lessons from accidents due to institutional failures: Boeing 737 MAX and Deepwater Horizon (DeepMaxLearn) project was commissioned by the Management Board of SAFIR2022 programme as a part of the SAFIR2022 administration project. Causes of accidents often have institutional origins and recent research highlighted the importance of better understanding the institutional perspective on disaster development (Verweijen and Lauche, 2019).
The objective of the DeepMaxLearn project was to analyse the institutional factors related to the Boeing 737 MAX and Deepwater Horizon accidents to provide STUK and the nuclear industry with relevant lessons and insights for the regulatory safety oversight and overall operations. The study focuses on institutional factors in the regulatory context, in the interaction between the authority and the operator and the weak signals that could have been detected in the operator's context and activities, including operator’s business and operational environment.
The study methods and data included a background interview with a retired pilot and aviation journalist, analytical desktop work, covering accident investigation reports; selected investigative and other media publications; annual reports of Boeing (2012-2018) and scientific articles, as well as a virtual workshop to present and discuss the results with the Radiation and Nuclear Safety Authority in Finland (STUK), representatives of the nuclear power companies in Finland and the Swedish Radiation Safety Authority SSM. Analysis was done by focusing on institutional factors – those relatively stable social structures, which shape the political, economic and social interactions over time to create order, reduce uncertainty and ensure legitimacy of organizations.
Results are presented regarding both cases of Boeing 737 MAX and Deepwater Horizon, followed by summary of the lessons learned and implications for the regulator and nuclear industry companies. Factors are elaborated with regards the role of national government and political influences, the importance of independence of the regulator, resources and competences of the regulator, critical changes in decision-making power of engineers, safety vs. profit tension and related drivers, organizational mergers and outsourcing as critical changes, role of educational institutions for framing the way of thinking and solving problems, the interlinkages between product safety, process/operational safety, and worker safety.
Original languageEnglish
PublisherVTT Technical Research Centre of Finland
Number of pages19
Publication statusPublished - Sept 2021
MoE publication typeD4 Published development or research report or study

Publication series

SeriesVTT Research Report


  • accident
  • institutions
  • safety
  • regulator


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